APPLICATION FOR REGISTRATION:
PRE-ENTRY ASSESSMENT PROGRAM FOR CLINICAL FELLOWS
Dear Applicant:
The College is pleased to provide this application for a Pre-Entry Assessment Program / Postgraduate
Education certificate of registration for International Medical Graduates (IMGs) with a confirmed Clinical
Fellowship appointment.
Note that this application package is specifically for IMG Clinical Fellows recognized as specialists
outside Canada or the USA. Applicants lacking specialty certification must instead pass the Medical Council of
Canada Evaluating Examination (MCCEE). Your Clinical Fellowship must be in the same discipline
(or sub-discipline) in which you are recognized as a specialist.
This application package contains the following:
•
•
•
•
•
Information about Exemptions and Specialty Certification
Requirements Checklist
Schedule of Requirements
Information about Certificates
Application, Credentialing, and Payment Forms
Before you commence your Clinical Fellowship, you must complete successfully a Pre-entry Assessment
Program (PEAP). During both the PEAP and Clinical Fellowship, you must be registered with the College and
hold the appropriate type of certificate. The College issues separate certificates for the PEAP and the Clinical
Fellowship.
For issuance of both certificates, you must complete this application form and all requirements set out in this
schedule. Issuance of the certificate for your Clinical Fellowship is automatic upon successful completion of
PEAP.
To ensure that your certificate is issued in time for your PEAP starting date, we recommend that you apply at
least four months in advance and follow all instructions carefully. This recommendation ensures that supporting
documentation is sent to the College in advance of your appointment.
For detailed information relating to the registration process and timelines, you must review the General
Guidelines document available under Related Links on the Registration Applications and Forms page.
Note that part of our application process requires you to complete source verification of your medical degree with
physiciansapply.ca, formerly the Physician Credentials Registry of Canada (PCRC). You should begin the
source verification process immediately.
Should you have any questions, please contact the Applications and Credentials Department at (416) 967-2617,
Monday to Friday 9:00 am to 5:00 pm.
The College looks forward to receiving your application and wishes you a successful and rewarding training
experience in Ontario.
Sincerely,
Applications and Credentials Department
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 1 of 11
IMG Clinical Fellow Application
EXEMPTIONS AND SPECIALTY CERTIFICATION
Option for Exemption from PEAP
The College does not require completion of PEAP if the Clinical Fellow has passed the certification examinations
or completed all of the training requirements for certification by one of the following:
(i)
The Royal College of Physicians and Surgeons of Canada,
(ii)
The College of Family Physicians of Canada,
(iii)
A Board of the American Board of Medical Specialties in the United States of America.
However, despite this option for exemption, the Ontario medical school may require the Clinical Fellow to enrol in
PEAP. In that case, the Clinical Fellow must apply to the College for a PEAP certificate.
If the medical school supports exemption, the Clinical Fellow must arrange for proof of Canadian or American
certification or eligibility to be sent to the College and must complete the rest of the requirements in this
schedule.
The College will then issue a Postgraduate Education certificate permitting direct entry into the Clinical
Fellowship without completion of PEAP.
Alternative to Speciality Certification
The only acceptable alternative to this requirement is successful completion of the Medical Council of Canada
Evaluating Examination (MCCEE).
Despite this alternative for the College, the Ontario medical school may require the Clinical Fellow to hold
speciality certification and recognition as a specialist outside Canada or the USA.
Exemption from PEAP
If you currently hold an equivalent Educational licence in another Canadian province or territory (except
Nunavut) your application will be reviewed under the provisions in the Ontario Regulated Health Professions Act
relating to the Agreement in Internal Trade (AIT).
These provisions may exempt you from the usual requirement for PEAP.
A letter from your current Program Director and a copy of your Educational licence will be required.
Your licence must be current and valid up to your Ontario starting date.
Clinical Fellows from the UK and Australia
For Clinical Fellows from the UK, recognition as a specialist for the purpose of the requirement on page 5 means
having the appropriate UK qualification (i.e. MRCP, FRCS, FRCA, FRCR or MRCOG) and having subsequently
completed all or most of the higher training of the Joint Committee on Higher Medical Training.
For Clinical Fellows from Australia, recognition as a specialist for the purpose of the requirement on page 5
means having passed the Fellowship examinations of the appropriate Australian specialist college (e.g. Royal
Australasian College of Physicians) and having completed all but the “Provisional Fellowship Year” of the
advanced training for admission to Australian Fellowship. The Provisional Fellowship Year is to be taken in
Ontario in a clinical fellowship program.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 2 of 11
REQUIREMENTS CHECKLIST
IMG Clinical Fellow Application
This checklist summarizes the schedule of requirements and is provided as a reference to organizing your application.
Please follow the instructions in the schedule when completing each requirement.
Part A:
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All Requirements in Part A must be Submitted to the College by the Applicant
1. Application Form (Enclosed)
Ensure all questions are answered and declaration on last page is properly completed.
2. Medical Degree from an Acceptable Medical School
Photocopy of your medical degree. Official translation required if not in English or French.
3. Specialty Certification and Recognition as a Specialist outside Canada or the USA
Photocopy of your specialist certificate. Official translation required if not in English or French.
4. Canadian Citizenship, Permanent Resident Status or Work Permit
Copy of valid passport or permanent resident card with date of birth shown, or valid Canadian Work Permit,
when available.
5.
Evidence of Name Change (if applicable)
6.
Passport (if applicable)
Copy of current passport required only if you are not a Canadian citizen or permanent resident.
7. Declaration for Breaks in Training or Practice History (Enclosed)
Using the form enclosed, explain any breaks of six months or longer in your training or practice history.
8. Professional Liability Protection (Enclosed)
Complete Undertaking or Declaration form.
9. Report from National Practitioner Data Bank
If you have practised or trained in the USA, obtain NPDB report.
10. Disclosure of Criminal Record Information
Arrange your own CPIC check – valid for 6 months from date of issuance. Do not wait for this requirement
to submit your application package to the College.
11. MINC Consent Form (Enclosed)
Sign and return MINC Consent form to enable issuance of (or verification of existing) MINC number.
12. Curriculum Vitae
Curriculum vitae must list all qualifications; dates/locations of all training and practice appointments.
13. Payment of Fees (Enclosed)
Must be enclosed with your application. Personal cheques not accepted.
Part B:
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All Requirements in Part B must be Sent to the College by Third Parties
14. Evidence of Standing (Enclosed)
Send CPSO form to licensing authority in every jurisdiction where you have practised or trained.
15. Letter of Appointment to Clinical Fellowship
Letter of Appointment to be sent to CPSO from Postgraduate office of Ontario medical school.
16. Statement of Objectives
Statement of objectives of your Clinical Fellowship to be obtained from Ontario medical school.
17. Verification of Medical Degree Credentials by physiciansapply.ca (Start Now)
Your medical degree must be source-verified through physiciansapply.ca and shared with the College. If
source verification is not completed before your appointment begins, arrange for your medical school to
send official academic transcript directly to the CPSO as a temporary alternative.
18. Verification of Non-Clinical or Non-Medical Employment
Reference letters for any observerships, research or health-related employment since medical school.
19. Inquiry Form for Board Action Search by the Federation of State Medical Boards (FSMB) (Enclosed)
If you have practised or trained in the USA, send Board Action Inquiry form to the FSMB.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 3 of 11
SCHEDULE OF REQUIREMENTS
IMG Clinical Fellow Application
This schedule contains detailed information regarding the requirements for registration:
•
PART A - The requirements to be returned by you
•
PART B - The requirements you must arrange to be completed by third parties.
All requirements in this schedule must be completed. Please follow instructions carefully.
PART A:
REQUIREMENTS TO BE SENT BY APPLICANT
1) Application Form
Your application form must be fully completed and the declaration on the last page must be signed and
sealed by a commissioner for oaths, notary public, or lawyer. If the lawyer does not use a seal, a
business card must be attached. An incomplete form or a form not properly notarized will be returned.
An application stamped by a Canadian embassy overseas is also acceptable.
In part 9 of the application form read the instructions and answer each question carefully. Every
”yes” response in sections (a) – (g) must be explained in writing and supported by the required
background documents or third-party reports.
In section (h), you will be required to report on exposure-prone procedures and blood-borne
pathogens. For assistance with these questions, we strongly recommend that you review the CPSO
policy on Blood Borne Viruses and FAQ. To access this material, select “Policies & Publications” on
the top menu, “Policy” and select “Blood Borne Viruses” under the “Practice” drop-down menu.
Any missed questions or incorrect responses will require correction and may delay your
application. Any conflicting or false responses will require written explanation.
Applications not completed after one year will be considered withdrawn.
2)
Medical Degree from an Acceptable Medical School
Photocopy of your medical degree from an acceptable medical school outside Canada or the United
States of America.
For the purpose of application for a certificate of registration in Ontario, a graduate from an acceptable
unaccredited medical school means a person holding an M.D. or equivalent basic degree in medicine,
based upon successful completion of a conventional undergraduate program of education in allopathic
medicine that:
(i)
teaches medical principles, knowledge and skills similar to those taught in undergraduate
programs of medical education at accredited medical schools in Canada or the United States of
America,
(ii)
includes at least 130 weeks of instruction over a minimum of thirty-six months, and
(iii)
was, at the time of graduation, listed in the World Directory of Medical Schools published by the
World Health Organization (WHO).
In 2007, the World Directory of Medical Schools was transferred to the AVICENNA Directory of Medical
Schools. If a medical school was added to the AVICENNA Directory of Medical Schools after the
transfer or was not listed in 7th Edition of the Directory of Medical Schools published by the WHO in
2000, your application must be reviewed by the Registration Committee.
With exception of medical degrees issued in Latin, all documents not written in the English or French
language must be accompanied by certified English or French translations. Please refer to the General
Guidelines document for information on acceptable translations.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 4 of 11
IMG Clinical Fellow Application
3)
SCHEDULE OF REQUIREMENTS – PART A
Specialty Certification and Recognition as a Specialist outside Canada or the USA
Photocopy of a certificate or letter confirming that you currently hold specialty certification by an
organization outside of Canada and the United States of America that certifies medical specialists.
If you do not yet have specialist certification but will obtain it before your clinical fellowship begins, send
a copy of your certificate as soon as it is available. Without satisfactory proof of current specialist
certification the College cannot issue your certificate of registration.
Applicants who are certified by the Royal College of Physicians and Surgeons of Canada or by an
American Specialty Board may submit evidence of this certification. Proof of eligibility for these
examinations is also acceptable.
All documents not written in the English or French language must be accompanied by certified English
or French translations. Please refer to the General Guidelines document for information on translations.
4)
Canadian Citizenship, Permanent Resident Status or Work Permit
One of the following is required:
a) Proof of valid Canadian citizenship (e.g. passport). Date of birth must be shown.
b) Proof of v al id Permanent Resident status under the Immigration and Refugee
Protection Act (photocopy of both sides of your Permanent Resident card issued by
Citizenship and Immigration Canada).
c) Photocopy of a Canadian Work Permit under the Immigration and Refugee Protection Act which
permits you to take the clinical fellowship program specified in your Letter of Appointment. Your
work permit will be issued upon your arrival in Ontario and should be submitted to the College at
that time. For most applicants, submission of the work permit is one of the final requirements.
Once your application is complete, the College will require at least two to three business days for
processing and issuing the PEAP certificate.
5)
Evidence of Name Change (if applicable)
Evidence of all official name changes must be submitted with your application (i.e. marriage certificate,
official court order). In entering your name on the register, the College will use the name provided on
your medical school documentation and supported by other identification documents unless you have
officially changed your name.
6)
Copy of your Current Passport (if applicable)
If you are not a Canadian citizen or permanent resident, you must submit a copy of your current
passport. Ensure that your copy includes the pages containing your photograph, personal details,
issuing country and passport expiry date.
7)
Declaration for Breaks in Training or Practice History
Using the Declaration form provided by the College, you must declare every break of six months or
longer in your postgraduate medical training or practice history. Be sure to include any delays occurring
between the date of your graduation from medical school and commencement of your postgraduate
training. Time spent in research and observerships should be declared.
Please ensure the dates provided are correct and match your application form and curriculum vitae.
Missing periods or conflicting dates will require clarification and completion of a new form. Should you
decide to apply for a new class of registration in the future, a new form must be submitted to the College.
In the application form you must also disclose all breaks of six months or more. All medical leaves of
absence must be disclosed, even those less than six months in duration.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 5 of 11
IMG Clinical Fellow Application
8)
SCHEDULE OF REQUIREMENTS – PART A
Professional Liability Protection in Ontario – Declaration or Undertaking
All applicants must have adequate professional liability protection, either from the Canadian Medical
Protective Association (CMPA) or an Ontario insurance company, or under the Treasury Board Policy for
Indemnification of Crown Servants of Canada.
(i)
Using the Declaration: Professional Liability Protection form provided by the College, you
must declare that you have professional liability protection that complies with the College’s
by-law. See the Declaration for further instructions.
(ii)
If you do not yet have professional liability protection in Ontario, complete the Undertaking:
Professional Liability Protection form provided by the College. Applicants seeking CMPA
coverage for the first time will need to complete the Undertaking. See the Undertaking form for
further instructions.
Although you can be registered by the College based on your Undertaking, you must not
commence any medical practice until you obtain professional liability protection. After you obtain
it, you must submit a Declaration by Member to the College within 30 days. The Declaration by
Member will be mailed to you by the College with your certificate of registration.
9)
Report from the National Practitioner Data Bank (NPDB)
If you have practised medicine or taken postgraduate medical training in the United States,
a “Self-Query” of NPDB is required.
You must submit to NPDB a Self-Query request for information disclosure, and then forward to the
College the report you receive from NPDB. If you receive a rejection notice from NPDB, do not forward it
to the College. Instead, re-submit your Self-Query to NPDB.
Note that the Self-Query must be submitted through the NPDB website. For further instructions and to
start the Self-Query process, go to http://www.npdb.hrsa.gov/.
10)
Disclosure of Criminal Record Information
You are required to arrange for a criminal record check using the Canadian Police Information Centre
(CPIC) database, which can be obtained from a municipal or provincial police service in Canada. A
vulnerable persons check is also acceptable. Checks by third-party commercial vendors, including
online vendors, are not accepted.
Ensure your CPIC check covers:
• Current and all previous names;
• Convictions and current charges – both are required
• Correct date of birth
Please refer to the “Guide for Acceptable Criminal Record Checks” on the College’s website for additional
assistance. Select the Registration menu at the top, followed by Registration Applications and Forms and
access the document on the right side of the page.
Once obtained, please forward your criminal record check results to the College. Do not wait for your
results to submit with your application, as this will delay the processing of your file.
If your check indicates a possible match in the CPIC system, fingerprint verification from the Royal
Canadian Mounted Police (RCMP) will be required to complete the screening process. You will be notified
if this applies to you.
Note: For applicants residing outside of Canada, you must take into consideration the processing
time of a minimum of 14 business days. Once processed, checks are valid 6 months from the date
of issuance.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 6 of 11
SCHEDULE OF REQUIREMENTS – PART A
IMG Clinical Fellow Application
11) MINC Consent Form
The MINC number is a national identifier unique to each physician in Canada, but contains no encoded
personal information. It is used by approved Canadian medical regulatory, administrative and research
bodies. See enclosure for further information.
Your completed MINC Consent form will enable the CPSO to arrange for issuance of your MINC
number. If you already have a MINC number or are not sure whether you have one, please provide your
MINC Consent. Only with your Consent can we check for your existing MINC number.
12) Curriculum Vitae
Your curriculum vitae must provide, at a minimum:
(i)
(ii)
(iii)
(iv)
(v)
Undergraduate medical education information and date of graduation
A listing, in chronological order (month/year) of all your postgraduate training appointments
including, durations and level of training in every jurisdiction since graduation
A listing, in chronological order (month/year) of all your professional appointments and type of
practice including names of hospitals and/or clinics, discipline, duration and location (please
specify the city, province/state, country)
A listing of all your previous and current medical licences including type, duration, licence
number and jurisdiction
A listing of specialist and other postgraduate examinations and qualifications
Any significant gaps in your training and practice history must be explained in the curriculum vitae.
13) Payment of Fees ($483.50)
Application Fee (non-refundable):
$164.50
Membership Fee:
$319.00
Fees must be submitted with your application. No assessment of your application will be made until the
application fee is received. The application fee is non-refundable regardless of whether your application
is incomplete, withdrawn or refused.
Payment must be made using Visa, American Express, MasterCard, money order or certified cheque
(payable to the College of Physicians and Surgeons of Ontario). Please use the form provided by the
College to authorize payment of fees by Visa, American Express or MasterCard.
Personal cheques are not accepted.
Receipt of your payment of fees by the College does not confirm that you are eligible for registration nor
does it confirm that your certificate of registration has been issued.
The application fee also includes Ontario Fairness Commissioner Registration Audit Recovery fee of $5.
Fees are subject to change.
submission.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Applications are subject to fee amounts in effect at time of
Page 7 of 11
PART B:
REQUIREMENTS TO BE SENT BY THIRD PARTY ORGANIZATIONS
•
You must arrange for the documents below to be sent directly to the College by third party
organizations.
•
Source documents sent by you will be rejected.
•
They must arrive by mail in an official, sealed and stamped envelope directly from the third party.
•
Courier delivery is acceptable, but the documents inside the courier package must be in an official
envelope that has been sealed by the source organization. Courier packages must be sent directly
to the College.
•
For all documents received by the College, not written in the English or French language, i.e.
medical school transcript or evidence of standing, you will be asked to arrange for translation.
Please refer to the General Guidelines document for information on acceptable translations.
14) Evidence of Standing
Using the “Confirmation of Standing” form provided by the College, you must provide evidence of
standing from the medical licensing authority in every jurisdiction where you have practised
medicine, or have taken postgraduate training since graduating from medical school. If the form
received does not cover your full period, a revised form will be required.
The evidence of standing from the jurisdiction where you are currently practising must also confirm your
recognition as a specialist. If specialist confirmation is missing, a revised form will be required.
A certificate of standing is acceptable in lieu of a completed “Confirmation of Standing” form only if the
licensing authority will not complete the Confirmation form and only if the certificate of standing attests to
the same information as required on the Confirmation form.
If you were not required to hold a licence to practise or train medicine in a jurisdiction, you must
arrange for a letter from your Program Director or Supervisor. It must be sent directly to the College in
an official, sealed and stamped envelope. It must confirm the dates of your appointment, type of
position, satisfactory performance and conduct and that no registration or licensure was required.
Applicants from the UK must ensure that the General Medical Council includes information on limited
registration on each certificate/letter of standing. If this information is missing, you will be asked to
arrange for revised evidence of standing. Copies of limited registration certificates may be acceptable in
certain cases.
If you were issued a certificate following successful completion of internship by your medical school,
please provide a photocopy with your application.
15) Letter of Appointment to Clinical Fellowship
A signed and dated Letter of Appointment issued by the Postgraduate Medical Education office of the
Ontario medical school at which you have an appointment as a Clinical Fellow. The Postgraduate office
will send the Letter of Appointment to you for your signature. You must return it to the Postgraduate
office, not the College. The Postgraduate office will then forward it to the College on your behalf.
The Letter of Appointment might not be available until later in the application process. Applicants should
continue with completion of other requirements while waiting for the Letter of Appointment.
16) Statement of Objectives
Applicants will receive a Statement of Objectives prepared by the Postgraduate Medical Education office
or Program Director in Ontario. The Postgraduate office will forward this requirement to the College
on your behalf.
The Statement of Objectives must set out the nature and purpose of your Clinical Fellowship. The
Statement of Objectives must be on official university letterhead and signed by the Program Director. It
must also include your name, start date, and specific objectives of your fellowship.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 8 of 11
IMG Clinical Fellow Application
SCHEDULE OF REQUIREMENTS – PART B
17) Verification of Medical Degree by physiciansapply.ca (formerly Physician Credentials Registry of
Canada)
Your medical degree must be source-verified by physiciansapply.ca and shared with the College:
Step 1:
Step 2:
Step 3:
Register with www.physiciansapply.ca; Physiciansapply.ca source-verification is
lengthy. You should start the process immediately.
Complete the procedures for physiciansapply.ca to carry out source-verification of your
medical degree.
Share your document(s) with the College.
If you have already completed source verification (i.e. for purpose of licensure elsewhere in Canada)
ensure that you share your verified credentials with the College by following the steps below:
1. Log into your physiciansapply.ca account and click on “Share Tab” in the Main Menu on the left.
2. Select the College of Physicians and Surgeons of Ontario (CPSO) from the list.
3. Select the documents to you wish to share with the CPSO. We recommend selecting all
documents.
4. Click the “Save and Return to Homepage” button to activate the sharing or “Save and Return to
List” should you wish to modify the list of organizations you wish to share with.
Once document sharing is activated, the selected documents and information can be viewed by the
CPSO staff at any time.
The College only requires verification of your medical degree by physiciansapply.ca. The decision to
have other documents verified is up to you.
If source verification of your medical degree through physiciansapply.ca is not completed before your
training appointment begins, the College will not hold up issuance of your certificate provided we can
confirm that source verification of your medical degree is underway (Status – Sent or Re-sent for Source
Verification) and we have received an official sealed transcript of your medical courses signed by the
dean or registrar of the medical school which granted your medical degree as a temporary alternative
directly from your medical school. All other requirements in this schedule must also have been
completed.
The transcript should contain the following:
• The dates you attended the school and date of graduation,
• All courses of the curriculum and the courses you completed,
• Your performance in courses and examination,
• Your clinical clerkship performance (must also specify rotations and duration).
A legible photocopy of your medical school transcript sent directly to the College by your medical school
will also be acceptable.
If your medical school does not issue transcripts in English or French, the College will accept
translations accompanied by documents in original language only if received directly from the medical
school and only if each page is dated and stamped by the medical school to verify the contents.
You will be required to provide an update on the status of source verification of your medical degree at
the end of PEAP.
If you attended more than one medical school, an official transcript will be required from each school.
You must also arrange for a letter from the first school confirming that your transfer was voluntary and
that you were in good standing at the time of transfer.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 9 of 11
IMG Clinical Fellow Application
SCHEDULE OF REQUIREMENTS – PART B
18) Verification of Observerships, Research, Health-Related Employment, etc.
After graduating from medical school, if you have undertaken any medicine observerships, shadowing or
research positions, or if you have been employed in health fields other than medicine (research for
example), arrange for your supervisor or employer for each position to send a letter to the College
confirming the dates of your position, duties, and satisfactory performance. If you were licensed with
another regulated health authority, official evidence of standing is required.
A letter is not required for any such positions that were less than one year in duration.
19) Inquiry Form for Board Action Search by the Federation of State Medical Boards
If you have practised medicine or taken postgraduate medical training in the United States, a board
action search by the Federation of State Medical Boards of the United States is required.
You must complete an Inquiry Form: Federation of State Medical Boards Action Data Bank form
provided by the College and send it directly to the Federation of State Medical Boards at the address
indicated in the form. The Federation will in turn send the Inquiry form directly to the College. You may
send the form to boardinquiry@fsmb.org
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 10 of 11
IMG Clinical Fellow Application
INFORMATION ABOUT CERTIFICATES
Pre-entry Assessment Program (PEAP) Certificate of Registration
All IMGs with appointments to a clinical fellowship in Ontario must complete a Pre-entry Assessment Program (PEAP).
The PEAP must be taken at the Ontario medical school offering the clinical fellowship.
The holder of a PEAP certificate of registration may practise medicine only:
(a)
in a clinical teaching unit that is formally affiliated with the Ontario medical school and only as part of a system
in which postgraduate trainees are regularly assigned by the program to that clinical teaching unit;
(b)
to the extent required to complete the pre-entry assessment program to which the holder is appointed; and
(c)
under a level of supervision that is determined to be appropriate for the holder and the program of medical
education and assessment, by a member of the College designated by the director of the program; and
(d)
may not charge a fee for medical services.
The PEAP must be a minimum of four and a maximum of twelve weeks in duration. The PEAP certificate expires
immediately upon completion of PEAP. The trainee must then cease practice and wait for the College to review the PEAP
Final Assessment.
If PEAP is completed successfully, the College will issue a Postgraduate Education certificate for the clinical fellowship.
Issuance of this certificate will normally occur on the next business day after the College receives the successful PEAP
Assessment. However, the trainee must not begin the clinical fellowship until the College has officially notified the trainee
that the Postgraduate Education certificate has been issued.
If PEAP is not completed successfully, the PEAP certificate immediately expires and cannot be re-issued. Enrolment in a
subsequent PEAP in the same discipline is not permitted.
Postgraduate Education Certificate of Registration
Following successful completion of PEAP, the College will issue a Postgraduate Education certificate of registration
authorizing practice as a clinical fellow. This certificate will carry the following standard terms, conditions and limitations:
1.
2.
3.
4.
The holder of this certificate shall practise medicine only as required by the postgraduate medical education
program in which the holder is enrolled at [Ontario medical school];
The holder shall prescribe drugs only for in-patients or out-patients of a clinical teaching unit that is formally affiliated
with the department where he or she is properly practising medicine and to which postgraduate trainees are
regularly assigned by the department as part of its program of postgraduate medical education;
The holder shall not charge a fee for medical services;
The certificate expires on the earlier of the following times:
a. When the holder is no longer enrolled in a program of postgraduate medical education provided by a
medical school in Ontario; or when
b. When the holder no longer holds Canadian citizenship, permanent resident status or a valid employment
authorization under the Immigration Act (Canada).
c. When three years have elapsed from the date the certificate is issued.
The certificate authorizing practice as a clinical fellow can be issued for a maximum of three years. Those wishing to extend
their appointment beyond three years must apply to the College’s Registration Committee for a new certificate of registration.
Such applications must be submitted several months in advance to allow for scheduling of Registration Committee review.
Transfers between Clinical Fellowships and Subsequent Clinical Fellowships
Your certificate of registration is valid only for the Clinical Fellowship indicated on the certificate.
If you wish to transfer to a different Clinical Fellowship, either at the same Ontario medical school or at a different Ontario
medical school, you will need to apply for a new certificate of registration. Your application will require review and approval
by the College’s Registration Committee.
If you have previously completed a Clinical Fellowship in Ontario and wish to take another, your application will require
review and approval by the Registration Committee.
To avoid delays in starting your new appointment, your application to the Registration Committee must be made several
months in advance of your anticipated start date.
Renewal of Postgraduate Education Certificate
Upon issuance of a certificate of registration, the applicant becomes a member of the College. Every Postgraduate Education
certificate carries an expiry date, which is usually based on the academic year-end. If the training appointment is extended, it
is the member’s responsibility to renew the certificate. It is an offence to practise with an expired certificate.
IMG Clinical Fellow – Instruction Guide
Revised: June 2016
Page 11 of 11
1+
The Coliege oi
@ Physicians and Surgeons of Ontario
Credit Card Payment Authorization Form for Registration Fees
Please complete this online form, print out and add your signature for your credit card payment.
Submission Options: (See instructions below. To avoid duplicate charge, please only submit once)
CPSO#/File#
Date
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Ad d ress
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Last Name
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Application Fee
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Postgraduate Education
MembershipFee PostgraduateEducation
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Practice and all other classes
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Membership
Fee
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Mail OR fax this form (but DO NOT do both to avoid
possible overcharge) to:
College of Physiclans and Surgeons of Ontario
80 College Street, Toronto, Ontario, M5G 2E2
Attention: Finance Departmenl Fax: 416-967-2654,
III
Print Form
Cotdholder signature
Please print out this form and sign above.
Reset Form
For Offlce Use Only
CPSO#/File#
First Name
Last Name
June 2016
Applications and Credentials Department
80 College Street, Toronto, Ontario, Canada M5G 2E2
Telephone: 416-967-2617; 1-800-268-7096 (In Canada only)
APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING
POSTGRADUATE EDUCATION
Incomplete applications or applications with missing pages will not be accepted. Please mail or courier the
original application. No action is taken on faxed or emailed applications. A non-refundable application fee must
be submitted with this application.
Affix
Photograph
Here
CPSO Registration or File Number
___________________
physiciansapply.ca Candidate Code ___________________
1. PERSONAL DETAILS
One black and white or colour photograph must be affixed above. Photograph must be full face, of passport size
and quality, and taken within six months of submitting this application.
a) The photograph of me attached hereto was taken on:
______/______/______
Day Month Year
b) Full Name: ____________________________________________________________________________
Last Name
______________________________________ ______________________________________
First Name
Middle Names
c) Have you ever been known by any other names?
Yes
□
No
□
If “Yes”, provide your previous names: _______________________________________________________
Last Name
______________________________________ ______________________________________
First Name
Middle Names
d) Date of Birth:
______/______/______
Day Month Year
e) Gender:
Male
□
Female
□
□
Are you a Canadian Citizen?
Yes
No
□
If not by birth, date granted:______/______/______
Day
Month Year
g) Do you hold Permanent Resident Status under the Immigration and Refugee Protection Act ( IRPA)?
f)
Yes
□
No
□
2 OF 16
h) Do you hold an employment authorization (visa or work permit) under the IRPA which enables you to
undertake the postgraduate training appointment specified in your Letter of Appointment issued by the
Postgraduate Medical Education office of an Ontario medical school where you have obtained such
appointment?
□
Yes □
Yes
i)
If “No”, are you now applying for such an employment authorization under the IRPA?
Have you previously applied for or been issued a licence or certificate of registration by the CPSO?
No
□
Clinical Fellowship
□
Yes
If “Yes”, please indicate your file or certificate number in the space provided by the photograph.
□
□
No □
No
2. POSTGRADUATE T RAINING APPOINTMENT DETAILS
a) Type of Postgraduate Training Appointment:
b) Anticipated Start Date:
Elective
□
Residency
□
______/______/______
Day
Month Year
c) Name of the Ontario medical school at which you have been offered a postgraduate training appointment:
___________________________________________________________________________________
d) Name of the department or program at which you have been offered a postgraduate training appointment:
___________________________________________________________________________________
e) Name of discipline in which you have been offered a postgraduate training appointment and training level:
___________________________________________________________________________________
3. CONTACT DETAILS
The mailing address you provide will be used as your official mailing address for communications from the
College. The training appointment address you provide will be recorded in the College register and will be
available to the public. Your mailing address will not be publicly available unless it is the same as your training
appointment address. Current email address must also be provided. As part of the application process,
you may receive information pertaining to your application that is confidential. It is therefore your
responsibility to ensure that your e-mail address is secure.
a) Present Mailing Address: _______________________________________________________________
______________________________________________________________________________________
Telephone Number: (____) ______ - ________
Alternate Telephone Number: (____) ______ - ________
b) Email Address: ________________________________________________________________________
c) Ontario Training Appointment Address:
__________________________________________________
______________________________________________________________________________________
Telephone Number: (____) ______ - ________
d) Future Mailing Address:
_______________________________________________________________
______________________________________________________________________________________
Future Telephone Number: (____) _____ - _______
Effective Date: ______/______/______
Day
Month Year
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
3 OF 16
4. MEDICAL EDUCATION
a) Name of your Medical Degree: _________________________________________________________
b) Date Granted: ________/________/________
Day
Month
Year
c) Name of University or School of Medicine granting your Medical Degree:
___________________________________________________________________________________
___________________________________________________________________________________
d) Address of University or School of Medicine granting your Medical Degree:
___________________________________________________________________________________
___________________________________________________________________________________
e) Period of time you were enrolled at this University or School of Medicine:
From: __________________/__________
Month
Year
f)
To:
__________________/__________
Month
Year
Your native language is: _______________________________________________________________
g) Language of instruction and/or language primarily used in patient care during the clinical parts of your
education at the University or School of Medicine granting your Medical Degree:
English
French
□
Yes □
Yes □
Yes
□
No □
No □
No
Other
If you answered “Yes” to “Other”, specify which language: ____________________________________
h) Before you graduated from the University or School of Medicine named above, did you attend any other
University or School of Medicine to receive part of your medical education?
Yes
□
No
□
If “Yes”, please specify:
Name of University or
School of Medicine
i)
From
Month/Year
To
Month/Year
/
/
/
/
Language of
Instruction
If you obtained a degree of Doctor of Osteopathic Medicine, please confirm it was granted by an
osteopathic medical school in the United States that was, at the time the degree was conferred,
accredited by the American Osteopathic Association (AOA):
Yes
j)
Location
□
No
□
N/A
□
If “Yes”, Date Granted: ______/_______/_______
Day
Month
Year
Name and Address of University or School of Medicine granting your Doctor of Osteopathic Medicine
Degree:
___________________________________________________________________________________
___________________________________________________________________________________
k) Period of time you were enrolled at this University or School of Medicine:
From: __________________/__________
Month
Year
To: __________________/__________
Month
Year
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
4 OF 16
5. POSTGRADUATE MEDICAL QUALIFICATIONS
a) Medical Council of Canada Examinations
Yes
Have you passed the Medical Council of Canada Evaluating Examination?
□
No
□
N/A
Examination Date: _____ /_____
Month
Have you passed, before December 31, 1991, the Medical Council of
Canada Qualifying Examination (before introduction of MCCQE Part 1 and
Part 2)?
U
U
Yes
□
No
□
N/A
U
□
No
□
Month
N/A
□
Year
□
Examination Date: _____ /_____
Month
Yes
Have you passed, after December 31, 1991, Part 2 of the Medical Council of
Canada Qualifying Examination?
U
Year
Examination Date: _____ /_____
Yes
Have you passed, after December 31, 1991, Part 1 of the Medical Council of
Canada Qualifying Examination?
U
□
□
No
□
N/A
Year
□
Examination Date: _____ /_____
U
Month
□
Year
□
Yes
No
Expected Examination Date:
_____ /_____
If “No” have you registered to take Part 2 of the Medical Council of Canada
Qualifying Examination?
Month Year
Yes
Do you hold Licentiate Certificate of the Medical Council of Canada (LMCC)?
□
No
□
N/A
□
Certification Date: _____ /_____
Month
Year
b) Equivalent to Medical Council of Canada Qualifying Examinations
Have you passed, before December 31, 1991, the examinations for the
Diploma of the National Board of Medical Examiners (NBME) of the United
States of America?
Yes
Have you obtained, before December 31, 1991, a score of seventy-five or
better on each of Component 1 and Component 2 of FLEX – the Licensing
Examination of the Federation of State Medical Boards of the United States
of America?
Yes
U
U
U
□
No
□
N/A
□
Examination Date: _____ /_____
Month
U
□
No
□
N/A
Year
□
Examination Date: _____ /_____
Month
Year
c) Acceptable Alternative to Medical Council of Canada Qualifying Examinations
Have you passed the the examinations for the Diploma of the National Board
of Medical Examiners (NBME) of the United States of America between
January 1, 1992 and December 31, 1994?
U
Yes
U
Have you obtained a score of seventy-five or better on each of Component 1
and Component 2 of FLEX – the Licensing Examination of the Federation of
State Medical Boards of the United States of America between January 1,
1992 and December 31, 1994?
U
U
□
No
□
N/A
□
Examination Date: _____ /_____
Month
Yes
□
No
□
N/A
Year
□
Examination Date: _____ /_____
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
Month
Year
FEBRUARY 2016
5 OF 16
Have you passed the United States Medical Licensing Examination (USMLE)
Steps 1, 2 and 3? The Step 2 Clinical Skills (CS) is required if Step 2 was
taken after June 12, 2004.
U
U
Step 1: _____/_____
Step 2: _____ /_____
Month Year
Month
Year
Step 1: _____/_____
□
No
□
N/A
□
Yes
□
No
□
N/A
□
Month Year
Have you obtained certification by the Educational Commission for Foreign
Medical Graduates (ECFMG), based on United States Medical Licensing
Examination (USMLE) Steps 1 and 2, plus USMLE Step 3? The USMLE
Step 2 Clinical Skills Assessment (CSA) component is required if ECFMG
certification was obtained between July 1, 1998, and June 14, 2004.
U
Yes
Step 3: _____/_____
Certification Date: _____ /_____
U
Step 2: _____ /_____
Month Year
Month
Month
Year
Step 3: _____/_____
Year
Month Year
Have you passed the Comprehensive Osteopathic Licensing Examination
(COMLEX-USA) Levels 1, 2 and 3? COMLEX-USA Level 2 Performance
Evaluation (PE) component is required if Level 2 was completed after
September 2004.
U
Step 1: _____/_____
Step 2: _____ /_____
Month Year
Month
□
No
□
N/A
□
Yes
□
No
□
N/A
□
Step 3: _____/_____
Year
Month Year
Have you passed the Examen Clinique Objectif Structuré (ECOS) of the
Collège des Médecins du Québec between 1992 and 2000?
U
Yes
U
Examination Date: _____ /_____
Month
Year
d) Royal College of Physicians and Surgeons of Canada Qualifications
Do you hold certification by examination by the Royal College of Physicians
and Surgeons of Canada?
U
Yes
U
Speciality: ______________________________________________
Sub-speciality, if applicable: ________________________________
If “No”, have you received an official assessment that you are eligible
without preconditions to take the oral and the written examination of
the Royal College of Physicians and Surgeons of Canada?
No
□
N/A
□
Certification Date: _____ /_____
Yes
□
Month
No
□
Year
N/A
□
Certification Date: _____ /_____
Month
□
U
U
□
□
Year
Yes
No
Expected Examination Date:
_____ /_____
Month Year
Do you hold certification without examination by the Royal College of
Physicians and Surgeons of Canada?
U
U
Yes
Specify Type of Certification: _______________________________
□
No
□
N/A
□
Certification Date: _____/ _____
Speciality: ______________________________________________
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
Month Year
FEBRUARY 2016
6 OF 16
e) College of Family Physicians of Canada Qualifications
Do you hold certification by examination by the College of Family Physicians
of Canada?
Speciality: ______________________________________________
U
U
□
U
U
Do you hold certification without examination by the College of Family
Physicians of Canada?
U
U
Specify Route to Certification: ______________________________
If “No”, have you submitted an application for certification without
examination?
□
Month Year
Sub-speciality, if applicable: ________________________________
If “No” have you received an official assessment that you are eligible
without preconditions to take the College of Family Physicians of
Canada examination?
□
Yes
No
N/A
Certification Date: _____ /_____
□
□
No
Yes
Expected Examination Date:
_____ /_____
Yes
□
No
□
Month Year
N/A
□
Certification Date: _____/ _____
Month Year
Yes
□
No
□
□
No
□
f) Qualifications by the American Board of Medical Specialties
Do you hold certification by the American Board of Medical Specialities?
Yes
N/A
□
Certification Date: _____ /_____
Speciality: ______________________________________________
If “No” have you received an official assessment that you are eligible
to take the oral and the written examination of the American Boards?
Month
□
□
Year
Yes
No
Expected Examination Date:
_____ /_____
Month Year
g) Other Qualifications
Are you certified as a medical specialist by an organization outside Canada
or United States that certifies medical specialists?
U
U
Yes
□
No
□
N/A
□
Name of Organization Granting the Medical Specialist Qualification:
_____________________________________________________________
Certification Date: _____ /_____
Month Year
Name of Speciality Certification:
_____________________________________________________________
Branch of medicine in which you hold speciality certification:
_____________________________________________________________
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
7 OF 16
6. POSTGRADUATE MEDICAL T RAINING COMPLETED IN C ANADA OR UNITED STATES
(a)
Internship (If Applicable) and Residency Training (PGY1<)
U
Level
Discipline
Medical School
From
Base Hospital
To
Month/Year
Month/Year
INT
/
/
PGY1
/
/
PGY2
/
/
PGY3
/
/
PGY4
/
/
PGY5
/
/
PGY6
/
/
PGY7
/
/
/
/
□
No□
Yes
Was your training performance in all internship, elective and residency rotations to date rated as
satisfactory by your Program Director? If “No”, please attach a comprehensive explanation and identify
the Program Director involved.
(b)
Clinical and Research Fellowships
U
Discipline
Medical School
Base Hospital
From
Month/Year
To
Month/Year
/
/
/
/
/
/
/
/
Was your training performance in all clinical or research fellowships to date rated as satisfactory
by your Program Director? If “No”, please attach a comprehensive explanation and identify the
Program Director involved.
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
□
No□
Yes
FEBRUARY 2016
8 OF 16
7. POSTGRADUATE MEDICAL TRAINING COMPLETED OUTSIDE CANADA OR UNITED STATES
a)
Internship (If Applicable) and Residency Training
U
Level
Discipline
Medical School
From
Base Hospital
To
Month/Year
Month/Year
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
□
No□
Yes
Was your training performance in all internship, elective and residency rotations to date rated as
satisfactory by your Program Director? If “No”, please attach a comprehensive explanation and identify
the Program Director involved.
b)
Clinical and Research Fellowships
U
Discipline
Medical School
Base Hospital
From
Month/Year
To
Month/Year
/
/
/
/
/
/
/
/
Was your training performance in all clinical or research fellowships to date rated as satisfactory
by your Program Director? If “No”, please attach a comprehensive explanation and identify the
Program Director involved.
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
□
No□
Yes
FEBRUARY 2016
9 OF 16
8. PRACTICE HISTORY
In chronological order, list the names of every jurisdiction where you have practiced medicine, including all
postgraduate training appointments since graduating from medical school . If you held or currently hold a licence
issued by a medical licensing authority, regardless of type, please provide the corresponding licence or
registration number for each period of postgraduate training and/or practice. Jurisdictions where you held a
licence, but did not engage in medical practice or training, are not required in this section.
U
l
U
Jurisdiction
(Province, State or Country)
U
Nature/Type of Postgraduate
Training and Medical Practice
From
To
Month/Year
Month/Year
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
Licence
Number
FEBRUARY 2016
10 OF 16
9. PROFESSIONALISM, CONDUCT, CHARACTER AND SUITABILITY TO PRACTISE MEDICINE
Each question must be answered carefully and honestly. Clarify any uncertainties with the College before you
answer the questions. If you do not fully understand what a question means or how it should be answered,
contact the College for assistance.
Any errors, discrepancies or omissions in your answers, no matter how minor, will delay your
application and may require review by the College’s Registration Committee.
U
Ensure that you consider any past practice in Ontario when answering the questions and that your answers are
consistent with those in any previous application you have made to the College.
For every “Yes” answer, you must provide sufficient explanation and documentation. Without this, the College
cannot proceed with your application. Later in the process, the College may ask you for further explanation or
documentation.
If the events or circumstances behind any “Yes” answer raise reasonable doubts about whether you fulfill the
registration requirements, your application must be referred to the Registration Committee for review.
Be assured, however, that not every “Yes” answer requires Registration Committee review, and that in either
case your honest and frank disclosure will be appreciated by the College.
The College has a non-exemptible requirement for registration that the conduct of the applicant, including the
applicant's past conduct, affords reasonable grounds for belief that the applicant:
U
(i)
(ii)
(iii)
(iv)
U
is mentally competent to practise medicine,
will practise medicine with decency, integrity and honesty and in accordance with the law,
has sufficient knowledge, skill and judgment to engage in the medical practice authorized by the
certificate, and
can communicate effectively and will display an appropriately professional attitude.
Knowingly giving a false answer to any question is grounds for refusal of the application by the Registration
Committee and is an offence under s. 92 of the Ontario Health Professions Procedural Code.
(a) APPLICATIONS TO MEDICAL LICENSING AUTHORITIES
In the following questions, “medical licence” includes any certificate of registration or permit to practise
medicine of any type -- full, limited, temporary, provisional, training, etc.
•
For every “Yes” answer, provide a detailed explanation including all relevant names and dates.
(i) Have you ever applied anywhere for a medical licence and been refused?
(ii) Have you ever been refused renewal of your medical licence?
(iii) Are you now applying for a medical licence in any jurisdiction other than Ontario?
□
Yes □
Yes □
Yes
□
No □
No □
No
(b) ACTIONS BY MEDICAL LICENSING AUTHORITIES
In the following questions, “medical licensing authority” includes the College of Physicians and Surgeons of
Ontario and any other licensing or regulatory authority that has had jurisdiction over your medical practice.
•
For every “Yes” answer, provide a detailed explanation and include copies of all relevant
documents in your possession. Later, the College may require you to arrange for the medical
licensing authority or other organization involved to forward further information directly to the
College.
•
For each complaint investigation, provide copies of the complaint, your formal response to the
complaint, and the decision and reasons. (For complaints in Ontario, you may omit this step.)
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
11 OF 16
(i)
Regardless of the outcome, have you ever been the subject of any complaint made to
a medical licensing authority? Be sure to disclose all complaints. Complaints that were
dismissed, or closed with no further action, or otherwise resolved in any manner, must
still be disclosed.
U
U
(ii) Are you now the subject of any complaint made to a medical licensing authority?
(iii) Have you ever been the subject of any type of investigation, inquiry or proceeding by a
medical licensing authority relating to your professional conduct, competence, capacity,
or any other aspect of your medical practice? Be sure to disclose all medical licensing
authority investigations, inquiries or proceedings, including any audits or assessments
of your practice.
U
U
Yes
□
Yes □
Yes
(iv) Are you now the subject of any type of investigation, inquiry or proceeding by a medical
licensing authority relating to your professional conduct, competence, capacity, or any
other aspect of your medical practice?
Yes
(v) Have you ever had a medical licence revoked, suspended, restricted, limited, or
subjected to any other adverse action?
Yes
(vi) Have you ever voluntarily entered into an undertaking or agreement, or voluntarily
restricted, resigned or surrendered your medical licence, either during or subsequent to
an inquiry, investigation or proceeding relating to your professional conduct,
competence, capacity, or to any other aspect of your medical practice?
Yes
(vii) Have you ever been required to enter into an undertaking or agreement, or been
required to restrict, resign or surrender your medical licence, either during or
subsequent to an inquiry, investigation or proceeding relating to your professional
conduct, competence, capacity, or to any other aspect of your medical practice?
Yes
U
U
□
□
□
□
□
No
□
□
No □
No
No
No
No
No
□
□
□
□
(c) LEGAL ACTIONS, SETTLEMENTS AND COURT FINDINGS
•
•
•
•
(i)
For each action or claim, provide an explanation of the events that led to the action, the patient’s condition at
the point of your involvement, the nature and extent of your involvement, and the degree of your
responsibility for the patient’s care. Also, provide copies of the statement of claim or complaint, statement of
defence or response, court judgment or court order, and settlement agreement.
For past actions in Canada, contact a Medical Officer at the Canadian Medical Protective Association
(CMPA) and authorize a report to be sent to the College that describes the action, your role in the events,
and the outcome of the action.
For current actions in Canada, contact the CMPA or your legal counsel and request a report to be sent to the
College that describes the action, your role in the events, and the present status of the action.
For actions outside Canada, contact your legal counsel or insurance carrier and request a report to be sent
to the College that describes the action, your role in the events and the outcome or present status of the
action.
Has there ever been any civil proceeding, legal action, insurance or other claim that
was in any way related to your practice of medicine or your professional activities?
(ii) Is there now any civil proceeding, legal action, insurance or other claim that is in any
way related to your practice of medicine or your professional activities?
(iii) Have you ever agreed to a settlement or other resolution to avoid or resolve any civil
proceeding, legal action or claim that was in any way related to your practice of
medicine or your professional activities?
(iv) Has a court ever made a finding against you in respect of a civil proceeding, legal action
or claim that was in any related to your practice of medicine or professional activities?
(v) Have you ever been denied professional liability protection or insurance?
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
□
Yes □
Yes □
Yes
□
Yes □
Yes
□
No □
No □
No
□
No □
No
FEBRUARY 2016
12 OF 16
(d) CHARGES AND CONVICTIONS
In the following questions, “ offence” includes driving offences such as impaired driving, dangerous driving,
driving while suspended, refusing to give a breath or blood sample, or failing to stop at the scene of an
accident – these are all major offences which must be disclosed. You need not disclose minor traffic
offences, such as parking violations.
U
(i)
U
•
For every “Yes” answer, provide a detailed explanation and include copies of relevant documents,
e.g. conviction, indictment or summons forms; conditional or absolute discharge orders; other court
orders and records.
•
If you have been granted a pardon for a past conviction, enclose a copy of the pardon document.
Have you ever pleaded guilty to, or been found guilty of, any offence?
(ii) Have you ever pleaded no contest or made any similar plea to any charge?
(iii) Are there any charges now pending against you for any offence?
(iv) Have you ever been charged or arrested for any offence?
(v) Have you ever entered a diversion program or other resolution process as an
alternative to conviction or prosecution for an offence?
□
Yes □
Yes □
Yes □
Yes □
Yes
□
No □
No □
No □
No □
No
(e) PRIVILEGES AND PROFESSIONAL EMPLOYMENT
(i)
•
For every “Yes” answer, provide a detailed explanation including all relevant names and dates.
•
Arrange for the chief of staff, department head, executive officer, or employer to send directly to the
College a report setting out the circumstances and reasons behind the action.
Have you ever been denied privileges or been denied appointment or reappointment to
the medical staff of a hospital or other health facility?
Yes
(ii) Have you ever withdrawn an application for privileges at a hospital or other health
facility?
Yes
(iii) Have you ever voluntarily relinquished or changed your privileges or resigned from a
hospital, health facility, or any other place of employment either during, subsequent to
or in expectation of, an inquiry, investigation or review that was in any way related to
your professional conduct, competence, capacity, or any other aspect of your medical
practice?
Yes
(iv) Have your privileges ever been revoked, suspended, cancelled, reduced or otherwise
changed by a hospital or other health facility?
Yes
(v) Have your privileges or legal authority to purchase, prescribe, possess or dispense
narcotic, controlled or designated drugs ever been restricted, reduced, withdrawn or
surrendered?
Yes
(vi) Are you now or have you ever been the subject of any type of investigation, inquiry,
review or action by a hospital, health facility, or any other place of employment relating
to your professional conduct, competence, capacity, or any aspect of your medical
practice? Be sure to disclose all such matters, regardless of outcome.
Yes
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
□
□
□
□
□
□
No
No
No
No
No
No
□
□
□
□
□
□
FEBRUARY 2016
13 OF 16
(f) MEDICAL EDUCATION AND ACADEMIC CONDUCT
•
For every “Yes” answer, provide a detailed explanation including all relevant names and dates.
•
For “Yes” answers relating to training, arrange for the undergraduate dean or the postgraduate dean or
program director to send directly to the College a letter setting out the circumstances and reasons
behind the matter.
Undergraduate Medical Education
(i)
Have you ever withdrawn from, or been expelled or suspended by a medical school?
Yes
(ii) Have you ever been put on probation or remediation by a medical school?
Yes
(iii) Have you ever taken a leave of absence of six months or longer from a medical school
or otherwise interrupted your undergraduate medical education for six months or
longer?
Yes
(iv) Have you ever transferred from one undergraduate medical education program to
another?
Yes
(v) Have you ever been the subject of any type of investigation, inquiry or proceeding
relating to misconduct of any type during your undergraduate medical education?
Yes
□
□
□
□
□
No
No
No
No
No
□
□
□
□
□
Postgraduate Medical Education
(vi) Have you ever been dismissed, suspended or removed from a postgraduate medical
training program?
Yes
(vii) Have you ever been put on probation or remediation during a postgraduate medical
training program?
Yes
(viii) Have you ever taken a leave of absence of six months or longer from or otherwise
interrupted a postgraduate medical training program for six months or longer?
Yes
(ix) Have you ever transferred from one postgraduate training program to another without
having fully completed the first program?
Yes
(x) Have you ever withdrawn or resigned from a postgraduate medical training program?
Yes
(xi) Have you ever been the subject of any type of investigation, inquiry or proceeding
relating to misconduct of any type during your postgraduate medical education?
Yes
□
□
□
□
□
□
No
No
No
No
No
No
□
□
□
□
□
□
General
(xii) Have you ever been investigated or sanctioned by any academic, research or medical
educational body of any type for any violation of academic policy?
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
Yes
□
No
□
FEBRUARY 2016
14 OF 16
(g) MEDICAL CONDITIONS (GENERAL)
In the following questions, “medical condition” includes any mental disorder or illness.
(i)
•
For every “Yes” answer, provide a detailed explanation.
•
For every “Yes” answer, you must also arrange for your treating physician(s) to send directly to the College a
report on your medical condition setting out your diagnosis, course of treatment, current health and prognosis.
Do you now have any medical condition that affects or could affect your ability to practise
medicine?
Yes
(ii) Have you ever had any medical condition that has affected or could affect your ability to
Yes
practise medicine?
(iii) Have you ever taken a medical leave of absence, of any duration, from a medical school, a
postgraduate medical training program or any professional position or employment?.
(iv) Are you now abusing, dependent on, or addicted to alcohol or a drug?
(v) Are you being treated for abuse of, dependence on, or addiction to alcohol or a drug?
(vi) Have you ever abused, been dependent on, or addicted to alcohol or a drug?
(vii) Have you ever been treated for abuse of, dependence on, or addiction to alcohol or a drug?
(viii) Do you now have a communicable disease or are you a carrier, whether asymptomatic or
otherwise of an infectious agent of a communicable disease (other than Hepatitis B,
Hepatitis C and HIV)?
Yes
□
□
□
□
Yes □
Yes □
Yes □
Yes □
Yes
No
No
No
□
□
□
□
No □
No □
No □
No □
No
(h) MEDICAL CONDITIONS (BLOOD BORNE VIRUSES)
•
(i)
For every “No” answer to questions (ii) to (vii), in bold, provide a detailed explanation. Once your application is
assessed, the College will follow up with you regarding your responses and advise you of further requirements.
In the coming year of your postgraduate training program/practice, will you
1.
2.
perform, assist in performing, or have the potential to perform or assist in performing
exposure-prone procedures (e.g. PGY-1 rotation in emergency medicine) as defined in
the Blood Borne Viruses policy?
OR
perform or assist in performing procedures that may become exposure-prone (e.g. a
laparoscopic that may convert to an open procedure)?
Yes
Yes
□
□
No
No
□
□
If "Yes" to either (1) or (2), answer questions (ii) to (v).
If "No" to (1) and (2), skip questions (ii) to (vii).
(ii) Have you had your blood tested for Hepatitis C and HIV in the past 12 months?
(iii) Are you infected with and/or have you had a positive blood test with respect to Hepatitis C or
HIV?
(iv) Have you been vaccinated against Hepatitis B virus?
(v) Have you had post-vaccination testing that confirms immunity to Hepatitis B virus? If "No",
provide a detailed explanation and answer (vi) and (vii).
(vi) Have you had your blood tested for Hepatitis B virus in the past 12 months? If "No", the
College will follow up with you regarding completion of the testing requirement.
(vii) Are you infected with or have you had a positive blood test with respect to Hepatitis B virus?
If you test positive for the surface antibodies only, answer "No".
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
□
Yes □
Yes
□
Yes □
Yes
Yes
Yes
□
□
□
No □
No
□
No □
No
No
No
□
□
FEBRUARY 2016
15 OF 16
(i) GENERAL
•
For every “Yes” answer, provide a detailed explanation.
(i) Have you ever ceased or interrupted your medical practice for any reason for six months
or longer? Please take note that all medical leaves of absence must be disclosed, even
those less than six months in duration.
Yes
(ii) Are you now subject to any contract, agreement, undertaking or obligation with any
medical licensing authority, health facility or other regulatory or governmental body that
might be an impediment to your application for a certificate of registration to practise
medicine in the province of Ontario?
Yes
(iii) Is there any event, circumstance, condition or matter not disclosed in your answers to
the preceding questions in respect of your character, conduct, competence or capacity
that might be relevant to your application for a certificate of registration to practise
medicine in the province of Ontario?
Yes
U
□
No
□
U
□
□
No
No
□
□
(j) UNDERSTANDING, AGREEMENT and THIRD-PARTY AUTHORIZATION
1) I understand that I will be deemed by the College of Physicians and Surgeons of Ontario (the “College”)
not to have satisfied the requirements and qualifications for a certificate of registration if, in connection
with this application or any past application, I have made a false or misleading representation, either
because of what was stated or left unstated.
2) I understand that any certificate of registration that results from this application is void and is deemed to
have always been void if I have made any false or misleading representation or declaration on or in
connection with this application, whether by commission or omission.
3) I agree that during the course of this application I will immediately notify the College in writing of
anything that renders any response to the questions in this application, although true and complete
when made, no longer true and complete. I understand that failure to notify the College of any such thing
may void any certificate of registration that results from this application.
4) I understand that the submission of this application for registration to the College and any registration
with the College that may result, shall constitute and operate as authorization by me for the College to
make such inquiries about me of any kind that it considers appropriate in connection with this application
and to disclose information about me to other medical licensing authorities, federations of licensing
authorities, hospitals and other institutions to which I apply for appointment.
5) I understand that this Understanding, Agreement and Third-party Authorization is valid commencing on
the date subscribed below and that this Understanding, Agreement and Third-party Authorization will
remain in force and effect during the course of this application and until I no longer hold a certificate of
registration issued by the College.
________________________________________________________
Applicant’s Full Name (Print)
________________________________________________________
Signature of Applicant
Date:
_______/ _______ / _______
Day
Month
Year
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
16 OF 16
Ensure to fully complete the declaration on this page. Your declaration must be made before
the Commissioner for Oaths, Lawyer, Notary Public or Justice of Peace while presenting the entire
application form. Application stamped by the Canadian embassy overseas is also acceptable.
Subsection 92 (1) (a) and (2) (a) of the Health Professions Procedural Code provide:
92 (1) (a) Every person who makes a representation, knowing it to be false, for the purpose of having a certificate of
registration issued is guilty of an offence and on conviction is liable to a fine of not more than $25,000 and not more than
$50,000 for a second or subsequent offence; 92 (2) (a) Every person who knowingly assists a person in committing an
offence under subsection (1) is guilty of an offence and on conviction is liable in the case of an individual, to a fine of not
more than $25,000 and not more than $50,000 for a second or subsequent offence.
DECLARATION
I, ________________________________________________________________________________________
Full Name
of the _________________________________________of _________________________________________
Type of Municipality (City, Town or County)
Name of Municipality (City, Town or County)
in the _________________________________________of _________________________________________
Province, State or Country
Name of Province, State or Country
hereby declare the following:
1.
2.
3.
4.
5.
6.
7.
I am the person making the application for a certificate of registration to practice medicine in the Province of
Ontario.
The photograph attached to the first page of the application is an unaltered photograph of me taken within six
months before the application is made.
I have, read, understood and signed the application to which this declaration is attached.
The answers I have given to the questions in the application to which this declaration is attached are true,
complete and without intent to mislead.
I understand that I am not permitted to engage in any kind of medical practice in Ontario until I have actually
been issued a certificate of registration authorizing such practice.
If the College of Physicians and Surgeons of Ontario issues a certificate of registration to me, I promise to
comply with the regulations and by-laws of the College.
I make this declaration conscientiously believing it to be true, and knowing that it is of the same force and
effect as if made under oath and by virtue of the Canada Evidence Act.
Declared before me in the _________________ of _______________________ in the ____________________
City, Town or County
Name of City, Town or County
Province, State or Country
of ____________________________ this day of___________________________________________20_____.
Name of Province, State or Country
_________________________________________________
Signature of a Commissioner for Oaths, Lawyer, Notary Public,
Justice of Peace or Canadian Embassy Official
Print Name and Address of Commissioner, Lawyer, Notary Public,
Justice of Peace or Canadian Embassy Official:
__________________________________________________
__________________________________________________
______________________________________
Signature of Applicant
SEAL, STAMP OR CARD
OF COMMISSIONER, LAWYER,
NOTARY PUBLIC, JUSTICE OF PEACE
OR CANADIAN EMBASSY
MUST BE AFFIXED HERE
__________________________________________________
__________________________________________________
CPSO APPLICATION FOR A CERTIFICATE OF REGISTRATION AUTHORIZING POSTGRADUATE EDUCATION
FEBRUARY 2016
DECLARATION:
To Account for Breaks in Training or Practice History
Instructions to Applicant:




Use this form to declare and account for all periods, since your
graduation from medical school, during which you did not practise
medicine either as a postgraduate clinical trainee or as a clinical
practitioner in any capacity (observerships and research appointments
included).
Declare only those periods of six continuous months or more.
Once completed, enclose with application form and return to the
College’s Registration Department.
Do not return form if you have no breaks to declare.
Applicant’s Declaration:
I declare that after I graduated from medical school, I ceased practising medicine for six continuous
months or more on the following occasions:
Dates
(mo./yr. to mo./yr.)
Reason for Break
(explain why you took a break, e.g. maternity leave, vacation, immigration;
attach additional pages as necessary)
____________________
__________________________________________________________________
____________________
__________________________________________________________________
____________________
__________________________________________________________________
____________________
__________________________________________________________________
I make this declaration conscientiously believing it to be true, and knowing that it is of the same legal
force and effect as if made under oath.
_________________________
Applicant’s Signature
_________________________
Print Name
___________________
Date
Rev. Jan/11
Undertaking by Applicant:
Professional Liability Protection
Under the College’s registration regulation, applicants for registration must have professional liability
protection in compliance with the College’s by-laws, as follows:
Each member shall obtain and maintain professional liability protection that extends to all areas of the
member’s practice, through one or more of,
(a) membership in the Canadian Medical Protective Association;
(b) a policy of professional liability insurance issued by a company licensed to carry on business in
Ontario that provides coverage of at least $10,000,000;
(c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for Crown
servants of Canada).
This Undertaking must be completed if you do not yet have professional liability protection in
Ontario and need to be registered with the College in order to qualify for professional liability
protection. For example, if you are applying to the Canadian Medical Protective Association for the
first time, you will need to complete this Undertaking.
This form must be signed, dated and returned to the College no more than six months in advance of
expected date of registration. An incomplete or outdated form will not be accepted.
Mail or fax completed form to:
Note:
Registration Department
College of Physicians and Surgeons of Ontario
80 College Street, Toronto, ON, Canada M5G 2E2
Fax: (416) 967-2623
You will need to submit a Declaration to the College within 30 days of obtaining your
professional liability protection. A form for this purpose will be enclosed with your
certificate of registration.
See over for Undertaking…
Page 1 of 2
Undertaking by Applicant:
Professional Liability Protection
I, ___________________________________________________________________, hereby undertake,
Full name of person applying for College registration
agree and consent to the College of Physicians and Surgeons of Ontario (“the College”) as follows:
1. Before I provide any medical service in Ontario to any person, I will obtain professional liability
protection that complies with s. 50.2 of the College by-law.
Specifically, my professional liability protection will extend to all areas of my practice and be provided
through one or more of,
(a) membership in the Canadian Medical Protective Association (“CMPA”);
(b) a policy of professional liability insurance issued by a company licensed to carry on
business in Ontario that provides coverage of at least $10,000,000.
(c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification
(for Crown servants of Canada).
2. Within thirty (30) days of obtaining such professional liability protection, I will sign and submit to the
College a declaration to that effect, using the College form “Declaration by Member: Professional
Liability Protection.”
3. I understand that after I am registered with the College and have identified the provider of my
professional liability protection, the College may inquire with the provider regarding whether I have
professional liability protection, and I hereby consent to disclosure of this information to the College by
the provider of my professional liability protection.
4. I understand that I must have available in my office, in written or electronic form, for inspection by the
College, evidence that I have professional liability protection.
5. I understand that my registration with the College will expire when I no longer have professional
liability protection.
6. I understand that before each annual renewal of my College registration, I must sign a declaration that
I have professional liability protection.
7. I understand that a breach of this undertaking is an act of professional misconduct which may result in
referral of a specified allegation against me of professional misconduct to the Discipline Committee of
the College.
____________________________________________
______________________________
Signature of applicant
_______________________________________________________
Print name of applicant
Mail or fax this completed form to:
Date
_____________________________________
College reference number (if known)
Registration Department
College of Physicians and Surgeons of Ontario
80 College Street, Toronto, ON, Canada M5G 2E2
Fax: (416) 967-2623
Note: Incomplete forms cannot be accepted and will be returned.
Reg Dept April 2009
Declaration by Applicant:
Professional Liability Protection
Under the College’s registration regulation, applicants for registration must have professional liability
protection in compliance with the College’s by-laws.
Applicants are required to sign a declaration that they comply with s. 50.2 of the by-law, as follows:
Each member shall obtain and maintain professional liability protection that extends to all areas of the
member’s practice, through one or more of,
(a) membership in the Canadian Medical Protective Association;
(b) a policy of professional liability insurance issued by a company licensed to carry on business in
Ontario that provides coverage of at least $10,000,000;
(c) coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for Crown
servants of Canada).
Complete and return this Declaration to the College as evidence of your professional liability
protection.
This form must be signed, dated and returned to the College no more than six months in advance of
expected date of registration. An incomplete or outdated form will not be accepted.
Mail or fax completed form to:
Registration Department
College of Physicians and Surgeons of Ontario
80 College Street, Toronto, ON, Canada M5G 2E2
Fax: (416) 967-2623
IMPORTANT! Do not complete this form if you do not yet have professional liability protection
and are applying to the Canadian Medical Protective Association. Instead, complete
the form “Undertaking by Applicant: Professional Liability Protection.”
See over for Declaration…
Page 1 of 2
Declaration by Applicant:
Professional Liability Protection
I, ______________________________________________________________________, hereby declare
Full name of person applying for College registration
to the College of Physicians and Surgeons of Ontario (“the College”) as follows:
1. I currently have professional liability protection that extends to all areas of my practice in Ontario.
2. My professional liability protection is provided through:
□
□
a)
membership in the Canadian Medical Protective
membership no.: _______________________, or
Association
(“CMPA”),
under
b)
a policy of professional liability insurance issued by a company licensed to carry on
business in Ontario that provides coverage of at least $10,000,000, namely
______________________________________________________________________, or
name of company and your policy number
□
c)
coverage under the Treasury Board Policy on Legal Assistance and Indemnification (for
Crown servants of Canada).
3. I understand that after I am registered with the College and have identified the provider of my
professional liability protection, the College may inquire with the provider regarding whether I have
professional liability protection in compliance with s. 50.2 of the College by-law, and I hereby consent
to disclosure of this information to the College by the provider of my professional liability protection.
4. I understand that I must have available in my office, in written or electronic form, for inspection by
the College, evidence that I have professional liability protection.
5. I understand that my registration with the College will expire when I no longer have professional
liability protection.
6. I understand that before each annual renewal of my College registration, I must sign a declaration that
I have professional liability protection.
7. I understand that it is an offence under s. 92 of the Health Professions Procedural Code to make
a false representation for the purpose of having a certificate of registration issued.
8. I understand that I will be deemed not to have satisfied the requirements and qualifications for
a certificate of registration if I have made a false or misleading representation in this Declaration.
____________________________________________
______________________________
Signature of applicant
_______________________________________________________
Print name of applicant
Mail or fax this completed form to:
Date
_____________________________________
College reference number (if known)
Registration Department
College of Physicians and Surgeons of Ontario
80 College Street, Toronto, ON, Canada M5G 2E2
Fax: (416) 967-2623
Note: Incomplete forms cannot be accepted and will be returned.
CPSO Registration Dept. – April/09
READ INSTRUCTIONS CAREFULLY:
DO NOT SEND INCOMPLETE FORM BACK TO THIS COLLEGE.
IT IS YOUR RESPONSIBILITY TO HAVE THIS FORM COMPLETED
BY ALL MEDICAL LICENSING AUTHORITIES WHERE YOU HAVE
BEEN REGISTERED.
INFORMATION PROVIDED ON THIS FORM IS VALID FOR
SIX MONTHS ONLY. UPDATED INFORMATION WILL BE REQUIRED IF
YOUR CERTIFICATE OF REGISTRATION IS NOT ISSUED WITHIN THAT PERIOD.
CONFIRMATION OF STANDING
by Medical Licensing Authority
Consent to Release Information
to the College of Physicians and Surgeons of Ontario
- This section to be completed by the Applicant To the Medical Licensing Authority in: __________________________________________________________
(province, state, territory or country)
I am applying for a certificate of registration to practise medicine in the province of Ontario, Canada, and
before my application can be assessed, information relating to my qualifications and medical practice
activities in your jurisdiction is required.
I hereby authorize your releasing to the College of Physicians and Surgeons of Ontario all information
requested below and any other information respecting me which you deem relevant to my present
application for a certificate of registration to practise medicine in Ontario, Canada.
I request the completed form and any appended information to be forwarded directly to:
The College of Physicians and Surgeons of Ontario
Registration Department
80 College Street
Toronto, Ontario, Canada
M5G 2E2
I understand you may require a fee for this service.
Full Name of Applicant (Print or Type)
_______________________________________
Licence Number
_______________________________________
Signature of Applicant
_______________________________________
Date
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Applicant’s Address
*Note to Applicant: A completed form is required from
the medical licensing authority in every jurisdiction
where you have practised medicine, postgraduate
training appointments included. Photocopy this form
if you need additional copies.
_______________________________________
Page 1 of 3
2 of 3
- This section to be completed by the Medical Licensing Authority -
1.
This is to verify that,
Dr.________________ ________________________________________________________
Full Name of Applicant
a)
b)
Graduated From: _________________________________________________________
Name of Medical School
Has been issued the following licence(s) by this medical licensing authority:
Type of Licence
Licence Number
Date Issued
Date Expired or Cancelled
month / year
c)
month / year
/
/
/
/
/
/
/
/
Has the following specialty qualification(s) which is recognized by this medical licensing
authority:
Specialty
Granted By
Date
________________________
________________________
___________/____________
________________________
________________________
___________/____________
________________________
________________________
___________/____________
month / year
d)
Undertook the following postgraduate training appointment(s) in the jurisdiction governed
by this medical licensing authority:
Type of Program
Hospital/University
From/To
________________________
________________________
___________/____________
________________________
________________________
___________/____________
________________________
________________________
___________/____________
month / year
3 of 3
2.
Has the above-named physician ever been the subject of an inquiry or an investigation by this
licensing authority involving an allegation of professional misconduct, incompetence, incapacity or
any like allegation?
Yes
3.
Is the above-named physician currently the subject of an inquiry or investigation by this licensing
authority involving an allegation of professional misconduct, incompetence, incapacity or any like
allegation?
Yes
4.
No
Does the above-named physician appear in the records of this licensing authority as having been
subject to reduced, suspended or cancelled privileges by a hospital due to incompetence,
negligence, incapacity or any form of professional misconduct?
Yes
5.
No
No
Have there ever been any disciplinary or fitness to practise findings, or any like findings, made by
this licensing authority against the above-named physician?
Yes
No
If “yes” has been answered to question 2, 3, 4 or 5 please provide all relevant information and
documentation.
Name and Title of Official for Medical Licensing Authority
Name of Medical Licensing Authority
Signature of Medical Licensing Authority Official
Date
Mailing Address
Email Address
Seal or Stamp of
Medical Licensing
Authority to be
Affixed Here
Telephone Number
Fax Number
*Note to the Licensing Authority: You may fax the completed form to the Registration Department,
College of Physicians and Surgeons of Ontario. Please ensure the original is mailed promptly.
Rev. July 2008
INQUIRY FORM: FEDERATION OF STATE MEDICAL BOARDS ACTION DATA BANK
APPLICANT:
Please complete and forward this form directly to the Federation of State Medical Boards by e-mail:
boardinquiry@fsmb.org. All search results are returned to the designated board electronically.
TO THE FEDERATION OF STATE MEDICAL BOARDS OF THE UNITED STATES:
I am applying for a certificate of registration to practise medicine in the province of Ontario, Canada,
and before my application can be assessed, information relating to my qualifications and medical practice
activities is required. I hereby authorize your releasing to the College of Physicians and Surgeons of Ontario
the results of your search for information about me in the Board Action Data Bank.
I request a summary report(s) and any appended information to be forwarded directly to:
The College of Physicians and Surgeons of Ontario
Applications and Credentials Department
80 College Street
Toronto, Ontario
M5G 2E2
My personal details are as follows:
Name:
Last Name
____________________
First Name
___________________________________________
Middle Name
Date of Birth: ___ _____ ____
Day Month Year
_________________________________________________________________________
Medical School: (Include Complete Name and, if applicable, Branch Location)
_________
Degree
_______________
Year of Graduation
___________________________________
Country of Medical School
ECFMG Number (for foreign medical graduates)
Physician's Signature
Updated: March 2016
_________________________ ___
U.S.A. Social Security No.
(if applicable)
Date
Consent for Release of Information to
Medical Identification Number for Canada (MINC)
To receive your Medical Identification Number for Canada (MINC), you need to complete this consent.
Please read the details about the MINC system and answer the question below.
A not-for-profit corporation, Medical Identification Number for Canada, known as “MINC#NIMC”, has been
incorporated by the Federation of Medical Regulatory Authorities of Canada (FMRAC) and the Medical Council
of Canada (MCC) for the sole purpose of administering the MINC number system.
This number will be issued to all health care professionals who consent in writing. Once assigned, an individual’s
MINC number will remain unchanged throughout his/her entire medical career. Assigned numbers are never
reused and individuals will carry the same number even if they leave Canada and return, move between
jurisdictions or change registration status.
The only information encoded in an individual’s MINC is a country code (CA for Canada) and a profession code
(MD for Medicine). The MINC number does not imply any special privilege, rights or status; it is simply a series
of letters and numbers for identification purposes.
When you consent, the College of Physicians and Surgeons of Ontario will submit your personal information to
MINC#NIMC as follows: name(s) (and previous name(s) if applicable), gender, date of birth, country of birth and
year and university of graduation, collectively referred to as the “Core Information”.
MINC#NIMC will use Core Information to either generate or confirm an existing MINC and will retain the Core
Information and its associated MINC in its system for the purposes of identifying individuals and ongoing identity
confirmation by Prime and Licensed Users of the MINC system.
“Prime Users” are those organizations that are authorized to request issuance of a MINC (the MCC and the
twelve Canadian medical regulatory authorities). “Licensed Users” are those organizations that have contracted
with MINC#NIMC to use these numbers.
Not-for-profit and public sector organizations that are involved in the education, certification, licensure or
professional practices of physicians in Canada may apply to MINC#NIMC for a license to use the MINC system
as a means of:
(i)
Accurately identifying individuals with whom they have dealings,
(ii)
Processing information relating to those individuals, and
(iii) Linking or exchanging physician information with other Licensed or Primary Users for Approved
Purposes such as the compilation of statistics, the development of profiles, the administration of
programs or benefits, the management of the health system and research.
Licensed Users agree to comply with MINC#NIMC’s Privacy Code, with privacy, security and confidentiality
provisions, and with applicable privacy legislation as part of their licensing agreements. The only information that
shall be disclosed to Licensed Users shall be the medical identification numbers for their own members. Prime
Users will have controlled access to both the MINC number and Core Information to facilitate the performance of
their regulatory responsibilities.
For a more complete description of MINC#NIMC, including its Privacy Code and a complete list of all Prime and
Licensed Users and their approved uses, consult the MINC#NIMC website at www.minc-nimc.ca.
Consent
I have read and understand the above information, and consent to the College of
Physicians and Surgeons of Ontario’s release of the Core Information to MINC#NIMC for
the purpose of generating a MINC number that will be permanently assigned to me or
checking my existing Core Information with MINC#NIMC.
I further consent to MINC#NIMC storing the MINC number in its database and disclosing the
MINC number to Prime and Licensed Users, as outlined above. I also understand that I may
withdraw my consent to MINC at any time, by written notice to MINC#NIMC.
□
No □
Yes
__________________________________
__________________________________ _________________
Print Full Name
Signature
CPSO Registration or Reference Number (if known):
Date
_____________
April 9, 2010